Tomorrow I have one patient in clinic. I'm doing a colonoscopy on her, and since she's the very first person I've ever done a colonoscopy on, it merits being blocked from 0845-1130. I've been practicing some, on the virtual colonoscopy machine. Post-call today (I had two admissions, one at 1 PM and one at 3 AM, isn't it always like that) I went and played with it some more. I spent over an hour on "a difficult colonoscopy" and wrestled over the same 20 cm of bowel until my arm ached and I was ready to either cry or throw the scope across the room. I couldn't get the biopsy tool to work for me to practice, either.I am terrified.

Pediatrics is going well, O Best Beloved, it is a light month and I can sometimes go home for call like last night. Sometimes I have 11 admissions in a day and then I do not go home, but most of the time that is a rarity. Also, kids tend to stay one or two days and recover quickly, so with call every fourth night I rarely have more than one or two carry-overs. Most of my time post-call is spent writing discharge summaries on the same kids I'd just admitted; waiting for staff to see them and write a note to fulfill legal requirements.Other than the one child I sent home with foster parents (I still need to tell that story) parents are here, interested in care, at the bedside, talking and asking questions. Kids laugh and roam around the halls. There is ice cream in the freezer. I admitted a DKA patient at 3 in the morning and the PICU nurses persisted in asking me questions about what to do next, as if I had any idea, but I gave them answers and kept moving, good enough to keep things going until I could call the admitting staff and staff things. At 3 in the morning, it is good to preface your statements. "Hi, this is Nykki the peds resident on call, I have your patient X here, the ER called about her?" A sleepy affirmation. "Kay, so she looks to be in DKA, and this is the first one I've done, just so you know. She was feeling poorly for a couple days..." Brief H&P, salient points only. Another few sleepy grunts. He doesn't make me stress over what to do, but I don't make him laundry list the orders either. "So I've got her tucked in, she got a liter in the ER of normal saline, she's still tachy, was thinking about running another one in and then switching to fast fluids..." We negotiate volume depletion (5-10%, in a 70-kg girl up to 7 kg or 7L of fluid deficit, give half in the first 12 hours), I ask about K replacement, give him lab values 2 and 3 times, as he needs them. "She's on an insulin drip, 7 units an hour, once she gets the sugar down to 300 or so do I drop the rate as well as switching to D5?" I sound like I know what I'm talking about - I skimmed UpToDate before she got to the floor, or I would know nothing. He grunts approval, instructions, labs. "Sounds good, if I have any trouble I'll call you."I meet him on the floor about five hours later, as he's rounding, a slim silver-haired man with glasses. Endocrinologists are a variegated bunch. "You did good," he says. "She's in great shape." His smile with the handshake is genuine. We talk about the plan, I hover to ask questions. Best to sound interested; she's the only interesting patient I have. Down the hall the six-day-old is not actually vomiting bile, she's just a happy spitter, a baby with mild reflux. The stable, happy, and alert two-month-old with meningitis is waiting out her IV antibiotics and her mother and I have had our limited conversation for the day. She's Hispanic, the attendings update her at the bedside with the translator. I smile and talk baby talk to the baby. "Quatro dias mas." "Esta bien?" "Si!" And that's our chat.

I must tell you about the CPS baby, about my twelve-year-old in the clinic who came in to start Depo-Provera, about the little boy who turned out not to be a shaken baby after all. But tomorrow morning comes early, so they say. There are two patients in the hospital whom I'll need to see, and the morning's scope, and that's it. Tuesday is a Day Off, during which I plan to sleep in and play games and perhaps even go work out. Wednesday is call again, but I don't dread it like Medicine call. And next month is Rural Medicine, and if I get it approved there will be a Whole Four Days of vacation time, plus a weekend, near the end of it, before the long winter haul begins.

It feels good to write. I keep forgetting how good it feels to write. I am neglecting you, O Best Beloved. Scold me.

ah. over here i don't think i've heard of any family docs doing colonoscopies. for that kind of thing you'd need a lot of practice - i'd imagine if you perfed someone and it came out that you do like 2 of them a year you'd pretty much have no defense.we do learn whatever procedures are done in our rotations, ie chest tubes on respirology and the like, but we don't have a number we have to hit to graduate. my staff and i actually put in a chest tube into an ER patient with a pneumo (the angiocath didn't work), and it was pretty funny, with us poring over the "ER procedures" book to make sure we get it right.

We do them in the GI colonoscopy suite - around here especially in the rural areas you get enough exposure, most of the time, to make it worth (1) doing and (2) feeling confident about it.The residency's pretty open about letting us learn anything we want, as long as it's germane to family medicine. We have a whole bunch of things we have to do - LP's, circumcisions, etc - mostly just to make sure we have a chance to do them with supervision.

The debate really isn't all that big - most parents still want them done, and the evidence is pretty scant one way or another. I imagine that if you had a serious objection to doing them that you wouldn't have to, our program director is -very- willing to flex the requirements as necessary.But one of the selling points of the program - one of the reasons that most of us came - is that the residency *will* teach you to do everything you could possibly need to do in family medicine, and then also give you the skills to decide what you *want*to do and *can* do.

OTOH, the beauty of family med is that if you ever decide you want to learn and practice a specific skill, you just find a willing specialist/trained family doc and follow them for a few days or weeks or however long it takes to learn it. most of the family docs i'm working with have done this at some point in their careers.

hell, if 10 years from now i decide i'll do circumcisions after all, i would not want to rely on the 3 times i did it in residency for my training.

True enough.But if I decide I want to set up shop immediately after residency (and several of our grads have done this) in a small town in rural Indiana where you're the only doc within 40 miles, let alone specialists to do things like that, then at least you're prepared to do so.Most of the residents who plan on doing scopes touch base with the GI docs, who let them do scopes in their offices with them pretty much whenever they have time to come over. We've actually got a great relationship with most of the specialists in town.

I'm almost two years out from medical school, here in Indiana where I was born and grew up. I used to write poetry - still do, sometimes - but now I've taken to spilling my heart out in prose. I'm balancing family, expecting a new baby, and working as a second-year family medicine resident. I'd like to take you along for the ride.

My updates are erratic, dependent on my mood, my current work schedule, and my ability to motivate myself. You are warned.

Expect a narrative of my days on shift. Anticipate good experiences and bad. Almost everything I write, personal or not, is a public entry, so be prepared for things that you don't quite understand.

There is a list of those who really do want to know more about me than the general public desires to see. Flip down to "spin a web" and click the link there to get in on that list.